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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Anger-Induced T-Wave Alternans Predicts Future Ventricular Arrhythmias in Patients With Implantable Cardioverter-Defibrillators

Rachel Lampert, MD, FACC^_*,_*, Vladimir Shusterman, MD, PhD, Matthew Burg, PhD^_*,, Craig McPherson, MD, FACC^_*, William Batsford, MD^_*, Anna Goldberg, BS and Robert Soufer, MD, FACC^_*,

^_* Yale University School of Medicine, New Haven, Connecticut
PinMed Inc. and University of Pittsburgh, Cardiovascular Institute, Pittsburgh, Pennsylvania
Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut

Manuscript received February 29, 2008; revised manuscript received October 14, 2008, accepted October 19, 2008.

^_* Reprint requests and correspondence: Dr. Rachel Lampert, Yale Cardiology, 333 Cedar Street, FMP 3, New Haven, Connecticut 06520 (Email: rachel.lampert{at}yale.edu).

Objectives: This study sought to determine whether T-wave alternans (TWA) induced by anger in a laboratory setting predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs).

Background: Anger can precipitate spontaneous ventricular tachycardia/ventricular fibrillation and induce TWA. Whether anger-induced TWA predicts future arrhythmias is unknown.

Methods: Sixty-two patients with ICDs underwent ambulatory electrocardiography during a mental stress protocol, 3 months after the ICD was implanted. T-wave alternans was analyzed using time-domain methods. After a 1 year follow-up, ICD stored data was reviewed to determine incidence of ICD-terminated ventricular tachycardia/ventricular fibrillation.

Results: Patients with ICD-terminated arrhythmias during follow-up (n = 10) had higher TWA induced by anger, 13.2 µV (interquartile range [IQR] 9.3 to 16 µV), compared with those patients without future ventricular arrhythmias, 9.3 µV (IQR 7.5 to 11.5 µV, p < 0.01). Patients in the highest quartile of anger-induced TWA (>11.9 µV, n = 15) were more likely to experience arrhythmias by 1 year than those in the lower quartiles (33% vs. 4%) and during extended follow-up (40% vs. 9%, p < 0.01 for both). In multivariable regression controlling for ejection fraction, prior clinical arrhythmia, and wide QRS, anger-induced TWA remained a significant predictor of arrhythmia, with likelihood in the top quartile 10.8 times that of other patients (95% confidence interval: 1.6 to 113, p < 0.05).

Conclusions: Anger-induced TWA predicts future ventricular arrhythmias in patients with ICDs, suggesting that emotion-induced repolarization instability may be 1 mechanism linking stress and sudden death. Whether there is a clinical role for anger-induced TWA testing requires further study.

Key Words: tachyarrhythmias (ventricular) • anger • implantable cardioverter-defibrillator

Abbreviations and Acronyms   ICD = implantable cardioverter-defibrillator   IQR = interquartile range   TWA = T-wave alternans   VT/VF = ventricular tachycardia/ventricular fibrillation

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